Early MRI useful in clinically suspected scaphoid fracture; no significant cost difference .
OrthoEvidence Journal (OE Journal) - ACE Report
OE Journal. 2016;4(14):15 Acta Orthop. 2015 Jun;86(3):303-9125 Norwegian patients, within a week of having acute wrist trauma requiring radiographic examination, were pseudo-randomized (based on the date of admission) to receive either early MRI treatment or standard treatment. The purpose of the study was to determine how early MRI compares with conventional management in treating suspected scaphoid fractures from a cost and efficacy perspective. Results indicated that the number of days absent from work and in a cast was significantly lower in the MRI group in patients without fractures, and no major difference was noted in the cost-minimization analysis.
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?
Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Sim = 1
Incerto = 0,5
Não relevante = 0
Não = 0
A Avaliação dos Critérios de Relato avalia a transparência com que os autores relatam as caraterísticas metodológicas e do ensaio na publicação. A avaliação está dividida em cinco categorias que são apresentadas de seguida.
1/4
Randomization
3/4
Outcome Measurements
4/4
Inclusion / Exclusion
4/4
Therapy Description
3/4
Statistics
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
O Índice de Fragilidade é uma ferramenta que auxilia na interpretação de achados significativos, fornecendo uma medida de força para um resultado. O Índice de Fragilidade representa o número de eventos consecutivos que precisam de ser adicionados a um resultado dicotómico para que o resultado deixe de ser significativo. Um número pequeno representa um resultado mais fraco e um número grande representa um resultado mais forte.
Porque é que este estudo era necessário agora?
Conventional treatment of occult scaphoid fractures involves wrist immobilization with radiographic reassessment 2 weeks later and studies have shown that 4/5 patients are immobilized unnecessarily. Acute MRI of the wrist has become a proficient method for ruling out injuries otherwise over treated and has been shown to reduce immobilization time in patients with suspected scaphoid fractures. However, no consensus was present at the time of this study about whether early MRI in suspected scaphoid fractures saves money as compared with conventional management. Thus the present study sought to determine the difference between the two treatments from an economic perspective in a Norwegian setting.
Qual era a principal questão de investigação?
How does early MRI compare with traditional radiographs and conventional management in the treatment of clinically suspected scaphoid fractures, from a cost and efficacy standpoint, in Norwegian patients?
- 7 scaphoid fractures were diagnosed in the MRI group and 4 in the control group with the number of other fractures also being higher in the MRI group than the control (n=22 vs. n=8)
- The numbers of consultations per patient were nearly identical between groups, and significant differences were found between the numbers of radiographs, the number of MRIs, and the numbers of elastic bandages used in the 2 groups
- The total number of days using a cast was lower for patients in the MRI group compared to the control group (MD= 4.6, p=0.05) and significantly lower in the MRI group in patients without fracture (MD= 13, p<0.005, 95% CI [11-15]) or without scaphoid fracture (MD= 6.5, p<0.005, 95% CI [3-10])
- In patients diagnosed with either scaphoid fractures (MD= 2.4, p=0.8) or other fractures (MD= 2.7, p=0.6), the number of days using a cast was similar
- Number of days of absence from work was not significantly different, yet for patients with no fractures, significantly fewer sick leave days were found for the MRI group (MD= 8 (3-13), p=0.002)
- No significant difference was present in the sum of all direct costs in the 2 groups (MRI group: 30,160 euros, Control group: 27, 997 euros) and the average direct medical cost of detecting/treating a patient with any occult wrist fracture was 1,160 euros in the MRI group and 2,545 euros in the control group
- Similar indirect costs were noted for the 2 groups (MRI group: 147,404 euros, Control group: 186,550 euros), yet in patients in paid work with no fracture indirect cost in the MRI group was less than half of the control
- Overall costs were marginally different between groups (MRI group: 177,564 euros, Control group: 214,548 euros)
De que é que me devo lembrar mais?
The number of days in a cast and absence from work was significantly lower in the MRI group in patients without fractures. No major difference was noted in the cost-minimization analysis in terms of overall costs.
Como é que isto afectará o tratamento dos meus doentes?
In a Norwegian setting, early MRI was useful in patients with clinically suspected scaphoid fracture and normal radiographs as it ruled out wrist fracture and decreased days in a cast and days on sick leave. However, the cost-minimization analysis found only marginal differences in overall costs between the groups. Further studies are warranted in other population subsets to determine the applicability of these results in the general population.
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